89-1837 - Laserfiche WebLink

Home Browse Search

'?"f.u.e_5_ A-M II APPLICATION FOR PERMIT z' I x SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {2091 466-6781 JUL 11989 II 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) "RONMENTAL HEALTH !I PERM+T� n Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. T &J1GEsn is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin k Local Health District. �I Job Address City B �c Lot Size PM k� Owner's Name � `��- % - "v Address f'�� . -__ _— Phone ContracEoi � Address �� 2z!ie 6, `T`"�ic se No. Phoneme �� r I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ ^--SYSTEM=REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i i FOUNDATION AGRICULTURE WELL OTHER WELL PITS?SUMPS _ l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout i I IrrigationF.-Approx. Depth I I Eastern Surface Seal Installed by I� Repair Work Done A Type of Pump H.P.C1Y� State Work Done Well Destruction ❑ Wei II Diameter Sealing Material (top 501 Depth Filler Material 18elow 501 t TYPE Of: SEPTIC WORK:--NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION € I (No septic system permitted if public sewer is l !i available within 200 feet.) Installation will serve: Residence__Commercial— Other Number of living units: ' Number of bedrooms t/y Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ �� Method of Disposal Distance to nearest: Well Foundation Property Line .p LEACHING LINE ❑ No. & Length of lines Total length/size ` FILTER BED LPistanC6 to nearest:. }. Well Foundation Property Line „ SEEPAGE PITS i I Depth Size _ Number �~ SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r employ any,person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." -�- k The applicant must tali for 1required,,inspections. Complete drawing o verses e. °4j ` l Signed Title: Date: r DEPARTMENT USE ONLY r �I Application Accepted by Date Area II Pit or Grout Inspection by Date Final Inspection by Date ZIP Ii 1 Additional Comments: 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J#f F INFO AMOU�N}T DUE AMOUNT REMITTED CLASH RECEIVED BY DATE p PERMIT'NO. q ..EH 13-24(REV.,,A 51 G l a 3 7 l EH 14-28 _ J 4 rt